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kz APPLICATION FOR PERMIT W SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA SEP 2 8 1pig. Telepho'ne (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEARIFROM DATE ISSUED : -ERMIT/'55ERVICES (Complete in Trlpli'6' te Application is hereby mad,to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address S C-;'7 Z RV6ty & Lot Size'-. P, , n4:� Owner's Name Address A/ -0041" Phone 7 0 Contractor s 16yo C2-;u_ License NO----------,—Phone TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT El DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR F OTHER C1 IK —DISTANCE TO NEAREST: SEPTIC.TANK,�-- SEWER LINES DISPOSAL-FLD.— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial 0 Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing *TO"M'estic/Private F-1 Gravel Pack E3 Tracy Type of Casing Specifications 0 Public 0 Other El Delta Depth of Grout Seal Type of Grout 17 Irrigation .1 --Approx� Depth 0 Eastern Surface Seal Installed by Repair Work Done POOOType of Pum�.e " N.P. State Work Done Well Destruction 13 Well Diametp:r, Sealing Material (top 501 Depth Filler Material (Below 501. TYPE OF SEPTIC WORK: NEW INSTALLATION El -REPAIR/ADDITION El DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial'— Other Number of living units: — Number of bedrooms— Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EJ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. 71 Method of Disposal Distance to nearest: Well Foundation— Property Line LEACHING LINE C -No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: well Foundation.— Property Line SEEPAGE PITS L-1 Depth Size Number SUMPS-- - El Distance to',nearest: Well'-- Foundation Property Line DISPOSAL PONDS ED i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following. "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in thd performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican;t, st 11 all re 'r Td i nions.ti Complete drawing on reverse side. c SignedX Title: Date: 91/21(//?110 FOR DEPARTMENT USE ONLY Application Accepted by M Date 10-1 r-40 Area Pit or Grout Inspection by Date Final Inspection by OYV%nl . Datd,¢ d EY 1s Additional Comments: VJ 4" 41, -r a "-ci-.; El Stk 466-8781 El Lodi 369-3621 El Man-57-0-T7104 El Tracy 835-M4Well leeves C,9,f4&Jz-s Applicant- Return ail copies to: Environmental He.alth Permit/Services 160I E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE_ AMOUNTREMITTE L D CK RECEIVED BY DATE PERMIT`NO.' INFO H + EH 13-24(REV11/86) EH 1426